Nokea
The nurse is supervising a student nurse teach a client about a newly prescribed medication. Which of the following actions, if observed by the nurse, would require an intervention?
- A. The student nurse glances at his/her watch when instructing the client.
- B. The student nurse uses culturally appropriate language and teaching materials.
- C. The student nurse begins instructions to the client discussing information that concerns the client.
- D. The student nurse chooses a time for teaching when there are no visitors.
Correct Answer: A
Rationale: lack of attending behaviors are always a barrier to learning
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The nurse observes the following patients in the emergency department (ED). The FIRST patient the nurse should see is the
- A. 34-year-old man with a distended abdomen and splenomegaly.
- B. 8-month-old infant with facial ecchymosis who is crying loudly.
- C. 12-year-old boy with a possible fractured ankle.
- D. 44-year-old woman with possible whiplash from an automobile accident.
Correct Answer: A
Rationale: possibility of internal bleeding, life-threatening situation
The neonatal nurse is instructing the family of a newborn about an apnea monitor.
The nurse should be MOST concerned if a family member makes which of the following statements?
- A. We will be able to leave our baby for brief periods of time.'
- B. We plan to sleep by our baby's crib.'
- C. We can remove the monitor during our baby's bath.'
- D. A family member will closely watch the monitor all the time.'
Correct Answer: D
Rationale: Strategy: 'MOST concerned' indicates that you are looking for an incorrect statement. (1) appropriate behavior (2) appropriate behavior (3) appropriate behavior (4) correct-indicates a feeling that monitor may not let them know if their infant stops breathing
The nurse is caring for a schizophrenic client who has become increasingly withdrawn to the point of mutism. The MOST important nursing approach at this time would be to
- A. ignore the client until he is ready to respond.
- B. sit with the client for brief periods of time.
- C. read to the client in a quiet area of the unit.
- D. encourage the client to play dominos with the group.
Correct Answer: B
Rationale: nurse should maintain contact with client but not make demands to communicate or participate in activities
The nurse is caring for a patient recovering from abdominal surgery. While ambulating, the patient complains to the nurse that she has a dull ache in her left leg. The nurse should
- A. place the patient on bedrest and elevate the foot of the bed six inches.
- B. ask the patient to remain in bed and place a pillow under the knee to elevate her left leg.
- C. ambulate the patient as directed to prevent complications of bedrest.
- D. obtain thigh-high compression or elastic stockings and continue ambulating the patient.
Correct Answer: A
Rationale: promotes venous return and decreases venous pressure relieving pain and edema
The nurse is assessing a client with suspected appendicitis. Which of the following findings would the nurse expect to observe?
- A. Pain relieved by pressure at McBurney's point.
- B. Rebound tenderness at McBurney's point.
- C. Pain in the left lower quadrant.
- D. Decreased bowel sounds in all quadrants.
Correct Answer: B
Rationale: rebound tenderness at McBurney's point is a classic sign of appendicitis